Drive-through screening and tent clinics are two of the contingencies under discussion by Hawaii hospitals in the event emergency rooms become swamped with feverish, coughing patients seeking treatment for flulike symptoms.

As a second wave of 2009 H1N1 influenza cases sweeps across parts of the Mainland, some hospitals there already are using such strategies to keep people sick with the flu out of regular emergency rooms, where they could infect severely ill patients.

Although H1N1 influenza, also called "novel H1N1" or swine flu, is the predominant influenza strain circulating in Hawaii, current flu activity is normal for this time of year, according to state epidemiologist Dr. Sarah Park, head of the Department of Health's Disease Outbreak and Control Division.

"Right now, knock on wood, we seem to have a bit of a lull. There's definitely flu activity in the community but it's at a manageable level," she said.

"The lull is giving everyone a breather and giving us a chance to focus on prevention before potentially any real activity starts hitting us. We're watching what's going on on the Mainland very closely and very nervously."

The timing of the lull in influenza cases is fortuitous for the state, since it coincides with the start of the Department of Health's annual vaccination drive for the seasonal flu and the arrival this month of the H1N1 vaccine, which is being administered first to health-care workers, children, pregnant women and people with chronic conditions that put them at risk for complications.

"We're keeping our fingers crossed that it's arrived in time so we can starting vaccinating the first in line and then eventually everyone else before any real activity takes off," Park said. "And if we're successful, a lot of people will be going, 'What's the big deal?' "

Cases of H1N1 influenza have been confirmed in all 50 states, with at least 37 states reporting widespread outbreaks, according to the U.S. Centers for Disease Control and Prevention. There have been nearly 600 deaths in the United States and more than 9,000 people hospitalized with the H1N1 flu. About 36,000 people die each year from the seasonal flu.

In Hawaii, there have been 11 H1N1-related deaths.

NO SURGE HERE YET

Unlike the seasonal flu, which typically has a greater impact on older individuals, the highest rates of infection with the H1N1 virus have been found in people younger than 25. H1N1 also is a particular threat to pregnant women and people with chronic health problems such as asthma and diabetes.

Even though most otherwise healthy people who come down with the H1N1 flu don't require medical treatment or anti-viral drugs and are able to recover at home, Mainland emergency rooms have been flooded with thousands of patients — some without flu symptoms but seeking reassurance, others seeking confirmation on whether or not they have H1N1, and some with symptoms who were directed to the emergency department by their physician.

In poll results released last week by the American College of Emergency Physicians, nearly 90 percent of surveyed emergency physicians expressed concerns about their emergency department's ability to care for additional patients.

"During our H1N1 wave in the summer that was a huge problem," said Dr. Erlaine Bello, an infectious disease specialist with The Queen's Medical Center. "The ER was clogged with what we termed 'the worried well' or people with influenza-like illness."

Cindy Kamikawa, vice president of nursing at Queen's, said patient traffic is more steady now and typical for this time of the year, with an average of 100 people a week showing up at the Emergency Department complaining of flu-like symptoms. That's less than a third of the total ER patient load, she said.

"It's not something we're real concerned about," she said. "It's normal for this time of year. We have not seen an increase or a high number of patients."

The majority of people reporting flu-like symptoms are treated and released, with a small number admitted to the hospital, more often than not because of other medical problems, Kamikawa said.

Queen's already has a policy of segregating possible flu sufferers in one area of its emergency department waiting room and providing masks to those with active coughs, she said.

'REALLY GOOD PLANS'

Officials from Queen's and other hospitals have been meeting regularly to prepare for a major H1N1 outbreak, said Toby Clairmont, director of emergency services for the Healthcare Association of Hawaii, whose members include hospitals and long-term-care facilities.

Plans are being made to "push services outside the building" if urgent-care facilities get overwhelmed, he said. Measures could include establishing drive-through and tent sites to screen and treat people with flu-like symptoms and setting up mobile temporary hospital wards.

With health care workers scheduled to get H1N1 immunizations well ahead of any anticipated surge in cases, hospital staffing during a major outbreak shouldn't be a concern, Clairmont said.

"We have really good plans and the resources, and it will work for Hawaii," he said.

Hospitals may consider implementing contingency plans "if we start hearing more about lots of people not able to come to work or staying home ill from school," Clairmont said.

For now, anxiety levels among health care providers and the public appear to be relatively low.

"We are not seeing the volume in illness that the Mainland is seeing, but that could change next week or next month," Clairmont said. "Right now people are asking questions and seem to be doing the right thing, such as staying home when they're sick. I don't see any drama except the drama generated by some of the reports coming out."

Clairmont was referring to this month's report by the Trust for America's Health that concluded that Hawaii is one of 15 states that could run out of available hospital beds during the peak of an outbreak, if 35 percent of the population were to get sick from the H1N1 virus.

The same group gave Hawaii a score of 8 out of a possible 10 in public health preparedness, based on factors such public health lab capabilities and plans for distributing anti-viral medications in a flu pandemic.

Clairmont said the hospital report didn't take into account contingency plans to provide additional beds.

"We're better off than you think," he said.

REGULAR FLU, TOO

In the meantime, health care officials are focusing on public education campaigns promoting hand washing to lessen the spread of infection, encouraging sick people to stay at home, and urging everyone to get separate vaccinations for the seasonal flu and the H1N1 influenza virus.

"The seasonal flu strain is out there, and getting a regular flu vaccination is just as important as getting an H1N1 vaccination," Park said.

Health officials said it's impossible to predict when or if a second wave of H1N1 may strike Hawaii, how severe it might be or how long an outbreak could last.

"If we look at what's happening on the Mainland, we saw areas with widespread flu early in the spring that went through a lull and now have a larger number of cases with people going back to school and outbreaks at colleges and universities However, New York City, one of the places hard hit in the spring, is in a lull period just the way we are," Bello said.

She said it's possible Hawaii residents have developed the same type of "herd immunity" from exposure to the H1N1 virus during the first outbreak that is apparently sparing New York from the worst of the second wave of cases.